Wrong-Site Surgery Cited as Top OR Safety Challenge Among U.S. Hospitals, Survey Finds

Despite being a rare event, wrong-site surgery is the No. 1 operating room (OR) safety concern for 65 percent of OR nurses in the United States, according to a new national survey conducted by Medline Industries, Inc. According to the Joint Commission Center for Transforming Healthcare, wrong site surgery occurs as often as 40 times per week in the U.S. Wrong-site surgeries include performing surgery on the wrong side or site of the body, on the wrong patient and performing the wrong surgery.

Wrong site surgeries are massively underreported, cautions Coleen Smith, RN, MBA, CPHQ, high reliability initiatives director for the Joint Commission Center for Transforming Healthcare. Dont assume you have good processes because you havent had a wrong site surgery.

The risk of wrong site surgery starts way before the patient approaches the operating room. It can start as early as the time that the patient is in the surgeons office and it is determined that surgery is necessary, Smith continued. At that point there could be a simple error in the scheduling request where a right or a left is written as an R or an L and those letters may be illegible or they get misinterpreted eventually leading to the surgeon working on the patients wrong side.

Medlines surgical safety survey, which elicited responses from more than 2,000 OR nurses from throughout the country, asked clinicians what their top three OR safety challenges were.

After wrong-site surgery, the second biggest OR safety concern cited was surgical site infections, or SSIs (63 percent), followed closely by retained surgical objects (60 percent).  According to the Centers for Disease Control and Prevention (CDC), SSIs are the most common healthcare-associated infection and account for 31 percent of all hospital infections. Between 500,000 and 750,000 SSIs occur each year in the U.S. and are associated with a 40 percent increase in hospital readmissions, according to the CDC.

Antibiotic timeliness and maintaining normothermia are among the most important solutions for reducing the risk of surgical site infections, says Kim Haines, RN, certified OR nurse and vice president of clinical resources for Medline. Patients with hypothermia in the OR are three times more likely to get a surgical site infection, so supplying uniform patient warming is crucial to lessening the chance of hypothermia and its complications.

Another notable finding from the survey showed 65 percent of respondents have experienced a sharps injury in the OR. The CDC estimates that 385,000 needlesticks and other sharps-related injuries are sustained by hospital-based healthcare personnel each year.  

Other survey highlights include:

 More than one quarter (27 percent) of respondents indicated that perioperative pressure ulcers were a major OR safety concern.

 Forty-two percent of hospitals are interested in learning more about ways to improve staff productivity and eliminate unnecessary waste in the OR.

A staff that feels confident that safety precautions are in place and they can do their jobs without fear of making a mistake or putting themselves or their patients at risk, will perform their best, says Haines. We are committed to finding new and innovative ways to help OR staff reduce the risk of adverse effects and enhance patient and staff safety.

In response to the challenges facing OR staff, Medline developed the EMPOWER Program, a comprehensive methodology to help healthcare leaders transform their OR through education, action and outcomes. EMPOWER offers a number of online clinical resources and training through Medline University, as well as OR safety product solutions for several key areas, including SSIs, perioperative pressure ulcers, post-surgical catheter-associated urinary tract infections, needlesticks, wrong site surgery, retained surgical objects and venous thromboembolism (VTE) prophylaxis.